Petition for Change of Name (For Adult Individual) Page 4 of 4
Form CAFC401 04/2016 This form is available for free at www.selfrepresent.mo.gov
Sign Below in the Presence of a Notary Public
Petitioner, of lawful age, being duly sworn on his or her oath, states that he or she is the petitioner named
above and that the facts stated in this Petition for Change of Name (For Adult Individual) are true according
to his or her best knowledge, information and belief.
(Sign above in the presence of a Notary Public) (Print your name above)
The following information must be completed by a notary public.
STATE OF )
COUNTY OF )
On this day of , 20 , before me personally appeared,
, to me known to be the person described in and
who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free
act and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County and
State aforesaid, the day and year first above written.
, Notary Public
County, State of Missouri
My commission expires:
This information may be completed by your attorney. Do not enter any information here if you are filing this case without
the assistance of an attorney.
I have assisted Petitioner in the preparation of these pleadings, but I am not entering my
appearance on behalf of Petitioner.
(Attorney - Sign above) (Missouri Bar Number)
(Attorney - Print your name above)
(Telephone Number with Area Code) (Fax Number with Area Code) (E-mail Address - Optional)